Beyond Hospital Doors: Nutaqsiivik A Model Perinatal Outreach & Support Program for High Social Risk Native Women

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1 Beyond Hospital Doors: Nutaqsiivik A Model Perinatal Outreach & Support Program for High Social Risk Native Women Sherri Noonan, RN, BSN Kelly Clement-Murphy, RN, MSN Suzanne Raelson, RN, CMC Southcentral Foundation Mission and Vision To improve the post-neonatal infant mortality rate for Anchorage Native infants Anchorage Native high social risk childbearing-age families will have access to the support and services they need to create safe home environments, strengthen their families, and move toward self-reliance 1

2 Creativity is the Key Meet clients where they are at (figuratively and literally!) Measure success as small changes in behaviors Advocate for clients with systems and don t be afraid to ask agencies why..? Non-judgmental actions and attitudes earn client s trust In 1993, the death rate for Alaska Native infants in the post-neonatal period (28 days through one year of age) was 3X higher than other Alaska infant population groups Participated in a Community-Wide Learning Collaborative (Institute for Healthcare Improvement - Boston) 2

3 A review of 27 Anchorage Native infant deaths identified how the system identified socially high risk pregnant women Flow charts led to points where gaps existed A standardized social risk tool was developed and has been in use since 1994 The Nutaqsiivik Program began with no new resources Existing staff were re-directed to begin pilot project one-stop concept clinic and home visiting services Tracking Days between Deaths has given us a short cycle measurement of infant mortality 3

4 Program Goals To promote safe home environments for high social risk infants To provide client-centered, risk-based interventions that will support the high social risk family in their efforts to move toward self-reliance To increase Alaska Native Medical Center s responsiveness to high social risk families To increase Anchorage community partnerships and awareness of the Nutaqsiivik Program s goals and activities To collect data and information to determine the nature and extent of need among high social risk Native families in Anchorage for program planning and evaluation 4

5 Foundation theory borrowed from the business world, used Quality Improvement techniques such as short cycle interventions PDCA (Plan-Do-Check-Act) Constant re-assessment of program activities Database with information regarding risk profiles of infants and mothers Social Risk Criteria Homelessness Current or recent DFYS involvement Positive urine drug screen for mother or infant Recent or current domestic violence Maternal substance abuse during pregnancy or at risk for relapse after pregnancy Current maternal psychiatric disorder or depression Lack of prenatal care or onset in 3rd trimester or inconsistent prenatal care FAS/FAE or otherwise cognitively impaired mother Age 16 or under History of SIDS History of childhood sexual abuse Worrisome parenting behaviors observed 5

6 Current Services High social risk pregnant women identified Referrals from wide variety of sources Home visitation begins after client accepts services, frequency based on family needs Home-based birth control consultation and administration Continual medical and social service coordination Transportation assistance to medical/social appointments Synagis administration in the home Immunizations in the home Intra and inter agency coordination of services and problem solving Support and advocacy Extensive case management for first year of life Individual case review every 90 days with physician advisor 6

7 Average number of days between deaths has gone from a pre-project baseline of 55 to 111 There is a continuing need for family support and services after the first year of life for approximately 1/3 of the families Nutaqsiivik spin-off activities derived from ongoing data evaluation: Teen Health Clinic Campus-wide domestic violence initiative Improved cognitive assessment system 7

8 Trends 1/3 of the Anchorage Native perinatal clients meet criteria for high social risk (approximately 150 families per year) Basic needs are often unmet (food, shelter, safety) The social isolation identified found to be striking Clients time orientation differed from the system that is trying to serve them A case review conducted in a one year period identified: 18% of the Nutaqsiivik mothers were FAS/FAE or otherwise cognitively impaired Mental health services were needed by 61% (only 16% receiving treatment) Substance treatment was needed by 33% (only 10% receiving treatment) 60% reported a lack of safe childcare 8

9 Pregnancy prevention services must be easily accessible and on-going Establish a clear mechanism for the diagnosis of cognitively impaired mothers Be creative about outreach and homebased health services Find ways to remove barriers to substance and mental health treatment Strategies That Work For Us Seek to understand the client s point of view Let them tell their story Be an active listener Each client is unique and wants consideration of their unique needs Be tenacious in your commitment to being flexible 9

10 Why Systems Fail the High Social Risk Client Inflexible entry points/intake opportunities create barriers Intake processes often miss the needs of cognitively impaired clients Long wait to enter treatment and delays in service delivery create situations where needs for shelter, food and safety may become higher priority Lack of transportation and child care is a recurring theme... Be aware of this THE BOTTOM LINE? Systems fail to serve the hard-toreach client when they are at a reachable moment so we lose them figure out when that moment is and be there with a service they can accept Nutaqsiivik clients receive services in ALL of our programs BE CREATIVE AND WILLING TO CHANGE HOW YOU PROVIDE YOUR SERVICE 10